Hernia or Psoas?

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Hello!

I’m still debating whether or not to have surgery for small, hidden, inguinal hernia. The pain is intermittent (i.e. a few days of significant discomfort followed a week or two of almost no pain). The pain is a pinching, pulling aching from the pubic bone to the hip. Sports and activity do not generally provoke pain so my life is not really limited per se – I’m just chronically uncomfortable. On bad days, I feel lousy. I lose my mojo and feel convinced that surgery is the right thing. But then it passes and I think (particularly after reading statistics and stories…) that I would be foolish to risk my relatively OK quality of life.

With hopes you can help me (and others) weigh my symptoms versus the risks, I have a few more questions:

– According to the Manual of Groin Pain recommended by (and with contributions from) Dr. Towfigh, “preoperative groin pain predicts an increased likelihood of postoperative chronic groin pain”. Can anyone clarify why this is so? Is it because groin pain is more often caused by something other than the hernia (as was told to me by one surgeon). As groin pain is a common symptom of hernia – and one of the main reasons for risking surgery – it’s something of a conundrum!

– Is intermittent pain typical of hernia? If so, would you say this is because pain is felt when the piece of tissue is lodged in the canal causing pressure – and relieved when it is not?

– Is bladder pressure a typical symptom of a small hernia? If so, is it because the bladder is literally being pressed upon or would this likely be a referred nerve issue?

– Is it possible that a hernia will become less painful when the hole gets bigger thus relieving some pressure or is it more likely to get worse as it progresses? (I seem to have pain less often than I did two years ago).

– Would nerve blocks be a viable alternative to surgery in some cases?

– And finally, is fatty tissue in danger of strangulation – or just bowel or bladder?

Many thanks.

[drtowfigh]

Hernia or Psoas?

If you are undergoing laparoscopic surgery, it is not so important to differentiate between inguinal and femoral hernias

What is important is the timing. Most of us agree that most inguinal hernias can be safely watched. Femoral hernias cannot. They should be repaired, especially if symptomatic.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Thank you, Dr. Towfigh – I appreciate your thoughts.

My pain now (2 years after onset) is improved in that I feel it less often and less severely than I did a year ago. It now falls in the grey area between ‘definitely wanting surgery’ and ‘thinking I can live with this’ – do you see any drawbacks or dangers in waiting until it gets worse ?

Also, do you often (or ever) encounter confusion between inguinal and femoral hernias on radiology reports and is it important to be rescanned prior to surgery? The exact centre of my pain is hard to pinpoint but it does extend from lateral of pubic bone to just below hip bone.

[drtowfigh]

Hernia or Psoas?

I disagree with most of the comments made to you.
I agree with Dr Vassiliou.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Hello Doctors,

I have an update: As I happened to be visiting Montreal in November, I took Dr. Earle’s recommendation, and arranged an appointment with Dr. Vassiliou. I explained my history and symptoms and gave her a copy of the ultrasound report which reads as follows:

“A very small left inguinal hernia located just lateral to the inferior epigastric artery. It contains only fat. It does not reduce completely at rest or with lying down. It increases slightly with Valsalva. The neck measures approximately 6mm”

There was no physical exam. She recommended I get the hernia fixed and that, if I didn’t mind traveling, she would be happy to perform the surgery (laparoscopically, with mesh) in the next few months.

Just last week I met with a local general surgeon (I am based in Calgary). In her opinion, a 6mm hernia is “insignificant” and barely bigger than the naturally occurring opening in that area. She explained that unless there is tissue further in the canal and creating a bulge, she would not recommend surgery. I asked about ‘hidden hernias’ and she did not seem to be aware of the concept.

Furthermore, she is not convinced that my symptoms are due to this hernia. She performed a physical exam and thought the area I indicated as most tender (just left of pubic bone) was a little low for an inguinal hernia. (It should be noted that when I had the ultrasound, the technician said it was femoral – I was surprised when the radiology report said inguinal). Also, when I mentioned that the pain at times extends up to the hip and wraps around to the back, she did not feel this was consistent with hernia. Her guess is that it is a pinched nerve or something musculoskeletal.

Also, in her opinion, patients who go into surgery with pain are more likely to have continued pain post-surgery. Her guess as to why is that the pain was not due to the hernia in the first place. (I am wondering if this is why the Shouldice Clinic won’t touch patients unless their hernias are palpable?)

This doctor suggests doing nothing except possibly acupuncture which might help if it is nerve pain. If or when the hernia gets bigger and detectable, she would then recommend I revisit the possibility of surgery.

Though I am not eager to have surgery and am willing to take a wait and see approach, I am dismayed at the notion that the hernia does not explain my pain! I feel intuitively that it IS the cause but know this could be wishful thinking. Needless to say, the second surgeon casts enough doubt that I am wary to go ahead with Dr. Vassiliou.

Does anyone have any thoughts or recommendations? Should I seek a third opinion? Wait and see? Thank you!

[Chaunce1234]

Hernia or Psoas?

If you’re willing to travel, consider Melina Vassiliou in Montreal. She’s a general surgeon who will listen, and is an expert in hernia repair. Hope this helps!

[drtowfigh]

Hernia or Psoas?

Great! So happy that this forum led to your correct diagnosis. It is the main goal of why we do this.

As to your questions:
– can you explain why small hernias are often more painful than large ones? I BELIEVE THAT SMALLER HERNIAS ARE MORE LIKELY TO HAVE THEIR CONTENT PINCHED, THUS THE GREATER PAIN.
– are small hernias any easier to repair? Is there a greater chance that a mesh would not be required (I am thin and so am wary of the mesh). YES. PERHAPS.
– are painful hernias trickier to repair because nerves are involved? NO.
– does the fact that the hernia is ‘occult’ mean that it is literally deeper in the groin and therefore more difficult (riskier) to repair? NO
– if left untreated, what is the likelihood of it getting bigger? 100%. BUT UNCLEAR OVER WHAT PERIOD OF TIME.
– is there an advantage to getting it repaired sooner (while I am still relatively young at 55) rather than later? ONLY IF YOUR ARE SYMPTOMATIC.

As long as your surgeon is skilled in the hernia repair procedure planned for you, and he/she confirms you have a hernia, then the experience with women’s hernia is not as necessary. Really, diagnosis is much more difficult in women than the operation itself.

We have had posts here about the Shouldice Clinic not accepting patients with hernias who do not have an obvious hernia on examination. I have personally reached out to the Shouldice Clinic Chief Surgeon to discuss this. They have strong historical data that in their experience, if they cannot feel for a hernia on examination, the patients are less likely to have as good an outcome. Not sure why that is. I do not have the same experience.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Hello Dr. Towfigh,

Well, I finally had a dynamic hernia ultrasound and a small hidden, inguinal hernia was found! The technician was very good and it was not until I was standing up and bearing down that she was able to detect it. There was no hint of it when I was lying flat – even after she knew exactly where to look. I’ve been told that the hernia is composed of fat and not intestine which (presumably?) means there is no risk of bowel incarceration.

After 2 years, I am greatly relieved to know the source of my pain even though my GP has warned that surgery is risky and could result in more pain. I am now in the queue to meet with a surgeon. I’m not sure who it will be or exactly how long I will wait. In the meantime, I hope you don’t mind if I run a few questions past you:

– can you explain why small hernias are often more painful than large ones?
– are small hernias any easier to repair? Is there a greater chance that a mesh would not be required (I am thin and so am wary of the mesh).
– are painful hernias trickier to repair because nerves are involved?
– does the fact that the hernia is ‘occult’ mean that it is literally deeper in the groin and therefore more difficult (riskier) to repair?
– if left untreated, what is the likelihood of it getting bigger?
– is there an advantage to getting it repaired sooner (while I am still relatively young at 55) rather than later?

I gather from other posts on your forum that the expertise of the surgeon is critical and that he/she should have 250 to 500 laparoscopies under her or her belt. Is it important that I ask if they’ve had specific experience with hidden hernias in women?

I have not contacted the Shouldice Clinic but have seen some negative reviews online. I have concerns about traveling across the country only to discover that they won’t believe a hernia is there because they can’t see it or feel it! (I’ve read that they don’t want to see scans?)

Again, thank you for this invaluable forum!

[drtowfigh]

Hernia or Psoas?

Correct.
Not all hernias cause pain with lifting, coughing, getting out of a car. You have to look at the whole spectrum of symptoms that it presents.
That said, the best is to be seen and evaluated in person to really know what is your diagnosis. The examination is very important as well.
I hope you can get help at the Shouldice Clinic, but if you cannot, please do revert back. I and others in the US are eager to give women such as yourself help in diagnosing your pain, even if it is not a hernia.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Thank you, Dr. Towfigh – this information is very helpful. I have one final question:

Even though my pain is not provoked by lifting, coughing, or getting out of a car – you would still say that a hernia is possible if not likely?

[drtowfigh]

Hernia or Psoas?

The normal Inguinal canal is a diagonal tunnel that travels through multiple layers of muscle. In women, that tunnel is large enough to accommodate the round ligament, the size of a noodle, and the genital nerve, the size of a thread. So, it’s a relatively narrow tunnel. If it dilates up due to weakened muscles or abdominal pressure, fat, and rarely intestine, can creep into it. In the early stages, the tunnel remains diagonal or angled, and it is hard for contents to easily travel through. If a piece of fat gets stuck in it, the pressure causes pain. Exercises such as Pilates can provide muscle support to reduce the gaping of the tunnel and reduce chances of the hole getting bigger. At later stages, the muscles surroinding and supporting the tunnel gape open, the tunnel is no longer a diagonal narrow tunnel, rather a wide direct tube or hole that allows for contents to go in and out. That is when a bulge is noticeable on examination. Prior to that, imaging is helpful to detect a hernia.
I usually do not offer laparoscopic exploration prior to imaging as there are instances where non-hernia diagnoses arise, such as hip labral tears, sacroiliitis, tumors, which may explain the groin pain. Also, once the hernia diagnosis is made, the discussion about the type of hernia repair is an important discussion to be had. Laparoscopic repair may not be the right choice for each patient. So preoperative planning is very important in order to tailor the repair to the needs of each patient.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Dear Dr. Towfigh,

Thank YOU for your helpful and thorough response! I’m glad I hit all your points (and no, I didn’t peek at your questionnaire!).

As neither the ultrasound nor MRI showed anything, my doctor and I had ruled out hernia. Also, as I had assumed that pain with coughing or lifting are hallmarks of hernias, I didn’t think one likely for me. Can you please confirm that this isn’t necessarily so? Is it dependent upon where in the groin the hernia is located? As my pain seems to extend from the left side of pubic bone up to the hip, I’ve often wondered if what I’m feeling is pressure on the inguinal ligament – does this make any sense to you?

I was interested in your quote to another poster regarding hidden hernias and strong core muscles:

“the hole is maintained and supported by strong surrounding muscles. I.e., you do not have a gaping hole with contents flowing out easily. Your abdominal muscles are trying to keep the hole as closed as possible”.

I’m assuming this means there is a hole in the muscle but that the bowel (or fat) only intermittently pokes through? And that the hole itself – with nothing poking through – is difficult to detect with imaging which is why you suggest manoeuvres during the scans? Would abdominal exercises (like pilates) be counter productive if trying to get a diagnosis as this would increase the chances of muscles closing the hole? Is it possible to actually mend a hernia with abdominal exercises (I’ll bet not!)

I will speak to my doctor and hopefully get a dynamic ultrasound and a referral to a surgeon. In your experience, are exploratory laparoscopies ever performed without a positive scan?

I only recently discovered that my mother has a hernia which prompted me to do more research. I’m glad I did – your forum and insights are most appreciated!

[drtowfigh]

Hernia or Psoas?

Wow, I wish all my patients came with such thorough and insightful histories. Thank you for that!

Well, you hit every single point that I usually tackle during the detailed hernia questionnaire that we go through during consultation (you can find a copy of it on my website if you don’t believe me!). You pretty much said “Yes” to everything on our list: pain at the groin that radiates up and around to the back and down the upper thigh, worse with sitting and standing, best with lying flat, associated nausea and bloating, notably worse with bull bladder and pain lingers after a bowel movement. Exercise does not make it worse, as most exercises do not cause an increase in abdominal pressure.

You do have a risk factor of hernia: family history. And we have noticed that a female link is stronger than a male link.

Ultrasounds for hernias must be done as a dynamic study. That means, standing, coughing, walking around. It should never be done while lying flat. That would likely result in a “false negative” study, that is, a report that says there is no hernia, when in fact there is one. In our study, we found that for small hernias, 50% of the time, the ultrasound was falsely negative. It is possible that this is because of technique more than the ultrasound quality itself.

If there is no actual bulge at your groin area, but your symptoms are suggestive of an inguinal hernia, then you fall into the category of an occult or hidden hernia. This is most likely to be found among women. In these circumstances, I recommend an ultrasound, and if that is not diagnostic, then a dynamic MRI. We have noted in our studies that the dynamic portion of the MRI pelvis is actually highly important in helping diagnose small occult hernias. A flat MRI pelvis may be adequate in many situations.

So, based on this assessment, which, granted, is based on your story, without any review of your films or any examination…

I do recommend that you seek a hernia specialist for your situation. You can start with a general surgeon who has interest in hernias, but most are not in tune with the concept of occult hernias among women, and so you may need to be patient and seek another consultant if the first one does not provide you with an answer to help rid you of your pain.

I am not familiar with specialists in Alberta. You can first try the Americas Hernia Society website (www.americanherniasociety.org) to see if any members live in your Province. The Shouldice Clinic in Ontario is another option, and I am in contact with them to discuss the concept of occult hernias among women.